What is the prescription for Pelvic Inflammatory Disease (PID) outpatient treatment?

From the Guidelines

For outpatient treatment of pelvic inflammatory disease (PID), I recommend a 14-day regimen of doxycycline 100 mg orally twice a day or clindamycin 450 mg orally four times a day, as these regimens provide coverage against the frequent etiologic agents of PID, including Chlamydia trachomatis and anaerobes. When considering treatment options, it's essential to prioritize regimens that have been evaluated for their efficacy in treating PID. According to the Centers for Disease Control and Prevention guidelines 1, doxycycline and clindamycin are recommended for outpatient treatment. Some key points to consider when prescribing outpatient treatment for PID include:

• Patients who do not respond to oral therapy within 72 hours should be reevaluated to confirm the diagnosis and should be administered parenteral therapy on either an outpatient or inpatient basis 1.
• The treatment regimen should be completed for a total of 14 days, even if symptoms resolve quickly, to prevent complications such as chronic pelvic pain, ectopic pregnancy, or infertility.
• Patients with tubo-ovarian abscess may require alternative regimens, such as clindamycin, which provides more effective anaerobic coverage 1.
• Emphasize the importance of completing the full treatment course and provide guidance on follow-up evaluation and potential side effects.

From the FDA Drug Label

PELVIC INFLAMMATORY DISEASE caused by Neisseria gonorrhoeae Ceftriaxone for Injection, USP, like other cephalosporins, has no activity against Chlamydia trachomatis. Therefore, when cephalosporins are used in the treatment of patients with pelvic inflammatory disease and Chlamydia trachomatis is one of the suspected pathogens, appropriate antichlamydial coverage should be added

Ceftriaxone for Injection, USP is indicated for the treatment of Pelvic Inflammatory Disease (PID) caused by Neisseria gonorrhoeae. However, since it has no activity against Chlamydia trachomatis, appropriate antichlamydial coverage should be added when Chlamydia trachomatis is suspected 2.

From the Research

Treatment Options for PID Outpatients

• The treatment of uncomplicated pelvic inflammatory disease (PID) typically involves broad-spectrum antibiotics that cover various pathogens, including Chlamydia trachomatis, Neisseria gonorrhoeae, anaerobes, and other organisms from the vaginal flora 3.
• A study published in 2009 found that a 14-day course of oral levofloxacin plus metronidazole was effective and well-tolerated in the treatment of outpatients with uncomplicated PID 3.
• Another study published in 2020 compared different antibiotic regimens for the treatment of PID and found that regimens containing azithromycin, quinolones, or cephalosporins had similar efficacy in treating mild-moderate PID, but the quality of evidence was generally low to very low 4.
• A 2019 study evaluated the susceptibility of endometrial isolates from women with PID to various antimicrobial agents and found that moxifloxacin had greater susceptibility than doxycycline for certain bacteria, including Gardnerella vaginalis and Atopobium vaginae 5.
• A randomized controlled trial published in 2021 found that the addition of metronidazole to ceftriaxone and doxycycline resulted in reduced endometrial anaerobes, decreased Mycoplasma genitalium, and reduced pelvic tenderness in women with acute PID 6.
• Guidelines published in 2019 recommend the use of ceftriaxone, doxycycline, and metronidazole as the first-line regimen for the treatment of uncomplicated PID, with fluoroquinolones (such as moxifloxacin) as alternative options 7.

Antibiotic Regimens

• Ceftriaxone plus doxycycline with or without metronidazole is a commonly recommended regimen for the treatment of PID 4, 6, 7.
• Levofloxacin plus metronidazole is another option for the treatment of uncomplicated PID 3.
• Moxifloxacin alone or in combination with metronidazole may be used as an alternative regimen, particularly in cases where Mycoplasma genitalium is suspected 5, 7.
• Azithromycin may be used as an alternative to doxycycline in certain cases, but the evidence is limited 4.